Saturday, April 29, 2006

Fragile

"Mary" was another of our tiny extremely premature neonates, one those babies who make up a small percentage of our admissions, make up a larger percentage of our patient days and an even larger percentage of our time and worries. She had bronchopulmonary dysplasia, the chronic lung disease that many of the tiny babies get, and had been on a ventilator for about six weeks. She wasn't out of the woods yet, but I thought that maybe, just maybe, she was turning the corner and starting to get better.

Then one morning I came to work and she wasn't there. The neonatologist on during the night said that he was called to her bedside in the wee hours of the morning because she was doing poorly and that by the time he arrived from the call room the baby was already dead. They tried resuscitating her, but to no avail.

What happened to her isn't clear. One of our NICU nurses had called in sick that night. A "pool" nurse, one from a nursing agency, was called in to take her place. Normally we wouldn't assign a pool nurse to a patient like Mary, a sick patient on a ventilator, because the pool nurses don't know the patients and might not be as confident in their NICU skills. It's hard to find good pool nurses. But staffing was short, we had other sick babies, and she had to do her part. About all we heard was that she was working with the baby, the baby went bad, and then couldn't be resuscitated. The baby also had some air filled blebs on her skin called subcutaneous emphysema.

Piecing things together, I suspect what happened is that the baby may have been "bagged" - given breaths with a ventilating bag - too hard, that is, given too big a breath for her lungs. I think she had a collapsed lung from that and it was too much for her to handle. If one of our own nurses had been taking care of her, one who knew her and knew how to bag properly, that baby might still be here. If a nurse hadn't called in sick, the baby might still be alive. I can't prove it and can't do much about it, except urge our nursing managers to keep us well staffed, but I'm not the only one who thinks that baby would be living if one our own nurses had been taking care of her that night.

Life is fragile, especially in an NICU. But it shouldn't be dependent on whether someone calls in sick or not.

P.S. I'm going to a conference in San Francisco for the next three days. I hope to have some internet access there and post a post in 2 days, but if I can't, I'll post when I get back.

12 Comments:

Blogger Dream Mom said...

What a sad story. But it's true. A lot can happen even with regular nurses-I have seen my share of hospital errors over the years and quite honestly, I can say that when I stay with Dear Son, I see at least one hospital error a day, that would occur, if I didn't stay with Dear Son. That is precisely why I choose to stay with Dear Son 24 hours a day, so I can be with him and call for help when needed. People think it's a luxury today to stay with your child-it's not a luxury, it's a necessity and it's hard work.

When you have a very sick child, for whatever reason, it's really hard. This example is a perfect illustration of that. My heart goes out to Mary today, it's always sad especially when they are so young.

12:44 PM  
Anonymous Anonymous said...

Very sad and unfortunate but what did you tell the parents?

3:57 PM  
Blogger Flea said...

Yikes! Careful ND, not to give too many details in a case with a bad outcome: the sharks are in the water!

Flea

7:03 PM  
Blogger Awesome Mom said...

This comment has been removed by a blog administrator.

7:07 PM  
Blogger Awesome Mom said...

It is hard in the NICU setting to really stay 24 hours with the baby. You don't get your own room like you do in a pediactric setting, so there is no place for the parents to sleep and there is very little room for them to even sit next to the baby. Plus it is a very crazy time for many parents and they may not know enough to stay with the child. Who is to say that even if (and we have no idea if there were ther or not at the time) the parents had been there they would have known enough to stop this from happening. Not every parent has the background or willingness to learn. The people that are a part of my son's ongoing care are always telling me how nice it is that I am so willing to do the research and learn things that are needed to care for my son.

I truly feel for the parents in this situation. It can't be easy to loose a child.

11:15 PM  
Anonymous Ged said...

Exactly why I don't like floating to other areas. Often the nurse who's been sent doesn't want to be there, feels uncomfortable with the patient group or what's being asked of them, or is unfamiliar with standard practice on that particular unit (even if their skillset might otherwise be appropriate for the job).

It's tough on everybody... the float nurse, the regular staff, the patients and family. And yet, we continue to do it. We will do so until we can staff every unit appropriately, and that won't happen until working conditions and compensation for skilled RN's improves across the board, drawing more people into the profession.

(Sorry to use your example as a political point, but I think you'll agree more skilled nurses is a good thing to aspire to!)

11:55 PM  
Blogger Ex Utero said...

Hi Neonatal Doc,

They have tons of computers here, you'll be able to continue blogging while at the convention. I can't speak to the nursing crisis in a personal way because that would violate HIPAA regulations regarding my own instituion, but I think we do have a problem nationally in that neonatal nursing (and probably ICU nursing in general) has been cut too lean in recent years. There is too much turn over, they are not given the professional respect they deserve by administrators and they get fed up and some times the only control they have over their lives is a sick call out (many times they come in when they're sick anyway, and use the sick call outs when they need a mental or personal holiday that management want let them have any other way - in my experience).

Your case illustrates the very real consequences of what is ultimately a decision made by your NICU management. Nurses have the right to be human and to be sick.

I understand that labor costs are the single most expensive NICU cost, but I think management currently has too much power in the management versus labor equation. We physicians need to be sensitive to this skewed dynamic and supportive of our colleagues. Its all to easy to blame the nurse that called out (and I don't mean to imply that you were doing that NeoDoc) or the nurse who was covering.

We as physicians need to be aggressive with management about capacity over-load in our units and cognizant of census that saturates nursing ability. In some cases, we need to teach management object lessons by transporting patients out of the unit for the simple reason that we deam that the overall care environment is unsafe. This goes against our grain and against our traditions, but in this world of finance is king, creating arbitrary caps based on communal patient safety is the best way I know to get the number cruncher's attention.

Neonatologist have been loath to get involved in these discussions. But what we're doing is allowing our managers to ration health care and the loosers are... the most vulnerable children who succumb to medication error or nursing inconsistency. This is bedside rationing, right here in the United States and we're letting it happen. And it has nothing to do with who has insurance or who can pay. It has to do with who is most vulnerable to medical error because managers are cutting out every possible safety net to save money.

Hope I run into you at the meeting.

12:19 PM  
Blogger neonataldoc said...

Thanks, everyone. Anonymous, I told the parents the truth, but I didn't tell them that I thought the pool nurse might have bagged too hard. It wouldn't be fair to do that without better information. Flea, you're right, I will be careful.

A few new NICU's are giving private rooms to babies, making it easier for parents to stay, but when a babby is hospitalised for 2 to 3 months, it's hard for them to stay all the time.

Ged and ex utero, I hear you. I've stayed out of nursing staffing decisions in our unit in the past, but I'm rethinking that.

8:34 PM  
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