Friday, November 24, 2006

Fracture

At the beginning of her shift the nurse noticed the baby was not moving his arm much and asked me to check it. The baby, born at 25 weeks gestation 8 weeks earlier, was still on a ventilator and pretty sick. Examining the arm, I noticed some swelling and redness in the upper arm. Father, who was there with me, made the diagnosis the same time I did. "Hey, that looks like it's broken," he said. I had to agree, and an X-ray confirmed it.

I think every NICU has had a broken arm in a tiny premie at one time or another. The very premature babies usually have relatively demineralized bones, for a combination of reasons, and it's easier to break them than it is the bones of a term baby. On the other hand, most tiny premies get through their NICU stay without a broken bone, in spite of demineralized bones, so if a baby has a broken arm, something has gone wrong. We don't know exactly when this baby broke his humerus. I suspect it occurred when he was being turned over or something like that, and perhaps his arm caught under him and snapped. The nurse wouldn't have even known it happened until the swelling started or they noticed it wasn't moving.

This was discouraging, to say the least. The parents were understandably upset and immediately started talking about transferring their baby to another NICU. I sighed to myself. We had maintained a good relationship with them through the baby's rocky NICU course so far, keeping them informed and being open with them, and it was disappointing to see that dissolve so quickly. Interestingly enough, they didn't seem that upset about the actual fracture itself but were angry that it hadn't been noticed and reported sooner (although, since we didn't know when it occurred, we don't really know how long it went unnoticed.)

It goes to show, I think, that we can never let our guard down in the NICU. You have to have a certain degree of compulsiveness to do well there. We can grow comfortable working there - we have to, or we couldn't stand it - but we cannot become complacent. You have to always be careful, whether you're writing IV orders, calculating an antibiotic dose, adjusting ventilator settings - or merely repositioning a baby with demineralized bones. Part of me is a little ticked at whoever did this for letting his or her guard down, but also, I know we all make mistakes.

The fractured bone is lined up nicely and the baby's arm should heal well. In fact, compared to the baby's lung and infection problems, plus his risk for neurodevelopmental problems secondary to prematurity, the fracture is a relatively minor thing. But for now, it takes center stage for the parents and therefore for us.

13 Comments:

Blogger NeoNurseChic said...

We've had babies have fractures - but there hasn't been any sort of blame game and I don't think any of the parents have been up in arms. One of our babies had a broken leg and then later a broken arm. I sort of wonder if her arm was broken during insertion of an IV. She has pretty bad demineralization and we have a lot of kids that they give a diagnosis of ricketts to. It seems every once in awhile, a fracture occurs. Now - I've taken care of the baby who had the broken leg and later the broken arm - and it was before the arm was broken - I pay very strict attention with everything I do....no doubt about that. When I turn a baby over, I am very careful that their arms aren't caught bent the wrong way or something like that - arms easily get tangled in tubes and wires or on the side of bedding, etc. I cannot remember any clear fracture of the arm - and we do not know when it occurred, but it happened. And later, when I saw that the arm was fractured, I wondered if it had happened when I was caring for her somehow. I doubt that it did - but when something happens to a baby you've cared for, your mind sort of freaks out and runs over everything 100 times.

To me, it seems we have a lot of kids with fragile bones who sometimes get either fractures or bone pain of some sort. We sometimes hang signs at the bedside that say something to the effect of, "My bones are very fragile. Please be careful when moving me! Thanks!" Do you guys put up any signs like that at some of the more chronic, tiny preemies' bedsides? We make signs for all sorts of things when we need a clear reminder that everyone sees constantly. Perhaps every tiny preemie should have a sign regarding the bones so that people remember to take extra care.

But anyway - since I've been there, I have no idea how many we've had with fractures - I know one transferred in to us with a bad arm fracture. It's not something we see often, but I have seen it a few times in the year and a half I've worked there!

I guess what I'm getting at is that I do take extreme care when turning them over or doing anything really - but sometimes I wonder if I have ever inadvertantly caused a fracture with something I've done during care because of the fact that it's near impossible to know if a bone has fractured in these little ones until, as you said, it begins to swell, etc... But it's yet one more reason to remind us all to be very mindful of where each limb and part is when doing care and moving them.

The one bothering me lately has been IV infiltrates/extravisations... Topic for a post someday. I've never had a baby get an extravisation on my watch, and I pray that I never do. The day I have that happen to one of my babies that I have on my shift, I will be very very upset. I'm one to check PIVs sometimes every half hour and sometimes even more frequently than that if I'm nervous about it. I catch blown IVs in my kids as early as possible, I'd have to say. The calcium is very unfortunate in the PIVs... Calcium burns those little veins so badly that I almost feel any kind of dextrose with adds should go through some sort of long, picc, or central line - something more solid. I remember getting electrolytes in the ICU and having to have them slow the rates down to as slow as mud to the point where a K+ rider took like 12 hours to go in...because it burns like hell. I bet it does burn them - and then it increases the likelihood of the extravisations. I get so nervous when I have a kid with dextrose with adds or hal/IL going through a PIV.

3:42 AM  
Blogger Flea said...

Did they transfer?

If so, ask yourself if you're willing to beat yourself up for your failure to be perfect.

You're not perfect and deep down the parents know it too. Don't let them punish you for your failure to be perfect. That's nuts.

Apologize, trouble shoot and move on.

best,

Flea

6:53 AM  
Blogger Fat Doctor said...

Remember, your treatment of patients is appropriate. I liked that post. Wasn't it just yesterday or so?

One time I intentionally fractured a clavicle to get a big baby delivered. It is one of the recommended techniques, you know. All other mechanisms had failed, the baby's took a long prolonged dip, and I really didn't have a choice.

The parents were more than miffed. They didn't notice that their baby was alive, in no small part due to my fracturing that clavicle. All they noticed was that I intentionally harmed of their beautiful new child.

I never saw them again - they transferred their care. It made me sad. But in the same circumstance, I'd do the same thing.

9:35 PM  
Anonymous Anonymous said...

NICU Mom here. I dont think the parents were out of line to wonder why it wasnt noticed by someone other than the Dad. I told the doc I thought one of my boys had pneumonia and three days later I got a call telling me the it was indeed true and that he was going back on the vent. I am not a medical professional but......
I wanted my boys transfered several times because of the lack of cohesiveness in the NICU staff. I demanded that there be a group of primary nurses that would take care of my boys on a regular basis. This really helped them get better and gave me piece of mind. Rememeber too many hands in the pot sours the brew.
It sounds like you are at least a good doc who really wants to make the families happy. Remember if you were in their same place with a 26 weeker you might feel the same. They just want something to go right with their baby so they can take him/her home.
As long as you are professional and upfront with them that's all you can do. Give them a little time and try to give them some little inkling of good news so they can believe that their little one will someday go home and they can be a happy family. And if they do transfer just learn from what happened and move on.
Signed,
Mom to 3 27 weekers now 7 1/2 months

11:14 PM  
Blogger Terrible Palsy said...

I think in the big scheme of things, a broken arm (particularly one that realigns without probs) is a non-issue in a prem that has respiratory and perhaps neurological probs. Eventually, the parents will see that too.

My hubby completely lost it at neo responsible for our baby's medical accident. 24 hours later, he had settled down and realised that everyone makes mistakes. Its just the heat of the moment.

I think a lot depends of whether those magic words are said - sorry.

4:17 AM  
Blogger neonataldoc said...

Thanks for the input. Neonursechic, I'm guessing you're bound to have an extravasation occur sometime, although I admire your attention to it. Flea, you're right. I have apologized and am trying to move on. The baby remains with us. The NICU the parents want to transfer to is full.

Fat docter, you're right too. We have to do what's right for the patient, even if it ticks off the parents.

Anonymous and TP, I'm sure it's a whole different ball game seeing it from the parents' viewpoint - but understanding completely the parents' view is easier said than done.

3:46 PM  
Blogger Tyg said...

I know this is a little old but I stumbled across it while looking for information to educate myself about my own premature son's breaks. I'm hoping maybe the blogger or someone still reads it.

I'm a mother of a 24 weeker who is now just over 4 months old and still in the NICU. Around a month after my son's birth they discovered he had a full left femur displacement. Like any parent my first reaction was to be very ticked to put it mildly. I settled down and accepted "tiny babies have weak bones." A few weeks after the first break they found an identicle break in the other leg. What really upset me about the second break was that I had noticed all the same actions in my son as I had prior to their finding the first break but my concerns were unheeded. It took another several days and just like the first leg they "accidentally" saw the break while filming another part of his body. "Thank God for poor radiolgist technique" my sister said when I called to tell her. To make my concerns worse there are NO pediatric orthopedic surgeons in my city. Since the first break I had asked over and over about sending him to a NICU that had one that could better manage his legs. Finally, after the second they agreed to send him to a larger hospital 2 hours away to be evaluated and a course of care planned by a pediatric orthopedic surgeon. I agreed to the genetic testing and every other thing they wanted to check. It ended up with a label of some really long osteo something. (Sorry I can't remember the entire term). So once again I accepted that "these things happen." I've never had an apology from any of the medical staff just always the "tiny bones are weak" and "these things happen." Now both of his legs are out of splints. There are signs all around his bed pointing out "handle me with gentleness" and "when lifting me roll me over or lift my hip DO NOT (and that's underlined several times) lift me by my legs" and "signed" by my son. I should add he was sent back to our hometown hospital 2 weeks after the surgeon evaluated him. Now what really really miffs me is the fact that here we have all of these signs pointing out how he should be handled and I have had to call twice in 2 weeks to complain of different nurses lifting him by his legs. I have 2 children at home, one being under 3 and not allowed in the NICU, so my time I'm able to come up there is limited. I've called upon family memebers who live farther away to come spend time with him at the hospital so we could keep a closer eye on him. Since doing this we keep seeing improper handling of him. So it leads me to wonder. If this is going on now, after they know there is an issue and there are warning and instruction signs, how were they handling him before when we hadn't worked out a schedule to keep closer "guard" of him? This isn't to say all of his nurses have been neglectful in their handling. He has a few nurses that are absolutely wonderful. I requested he have more than one primary assigned to keep better collective information, that has been another problem with his nurses changing all the time and nobody really "knowing" anything, so there were fewer incidents of being told "I wasn't told anything about that." every time I inquired about a test result, when another test was scheduled, and sometimes even with how his feedings had been that day. His night primary is wonderful. When she hears of a slip in his care she immediately goes to the charge nurse and ensures that the nurse is approached and has his process of care reaffirmed to him or her. I try and have tried very hard to look at things from the medical staff view. I've done my best to calm myself quickly when things happen. But can anyone really justify or brush off with the "these things happen" when these things occur when they for one were not there to see how the child was handled all the time? I try not to put his nurses on the defensive. When I went to visit him yesterday I saw yet again his nurse lifting him by his legs so all I said was "You know, when I change his diaper I just remind myself before I start and read over his signs again about how he's supposed to be handled because I understand how easy it is by looking at him to not have the problems with his legs spring to mind." I tried pointing out that no I didn't think she or myself for that matter never made mistakes but to put a little extra care in our actions. I guess I did still make her defensive because I was met with a flurry of excuses. The worst part being "well I was talking and forgot." To me it seems like working in a NICU would be high stress with lots of chances for greater distractions. Caring for a baby and suddenly another baby in your care has alarms going off. So if nurses are so easily distracted they "forget" proper care just by answering "How has he been today?" How do they manage when they have major distractions occur? I'm sorry to be so long winded but this seemed like a wonderful place to point out a parents view and possibly get feedback from other NICU care givers on maybe another way I need to look at things to better understand the position of my son's care givers. I really am trying very hard to be understanding and look at things from their angle but after the last couple weeks it is becomming increasingly hard. As one poster pointed out a break is a minor problem compared to others and yes I do realize that. But one thing I would like to point out and what I have stated over and over to the staff at our NICU..."A baby with so many other serious problems doesn't need anymore even smaller problems added on top making their growth and development even harder." That was a major concern of mine with the breaks. How much harder is this going to make his recovering from A, B, or C? He's lactose intolerant but since his legs were slow on healing he had to continue taking a formula with lactose to get the better nutrition to aid his legs. After started the more nutrient rich formula his legs did start to heal faster but he is now constantly uncomfortable with gas. While pushing for his gas he's continually spitting up large portions of his feedings so he's not even getting his full feeding. This is also leading to his choking more often when he does spit up. When he chokes he brady's. So in my view, as a parent, these "minor" problems have a large impact on the greater problems. Please tell my your view and help me try to understand how I'm looking at things wrong. I really do need reassurance that I am just an overly worried parent and the hospital staff are doing everything that is best. 4 months in the NICU is taking it's toll on my whits.

12:54 PM  
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Blogger Randi Unrau said...

If it was your child would a broken limb be a "nonissue"? Coming from a momma of a NICU baby with respiratory and possible neurodevelopmental problems, does my baby's broken bones causing them intense pain not matter because they have bigger problems?
You are absolutely right about the words "sorry"... they go a long way with us. We were just informed yesterday that our babe had a fractured femur (possibly from weeks ago, since when he has been extremely irritable and in pain, and no one had been able to figure out why).
Regardless of whose fault it was or how easily it can happen with my baby, it's not a "nonissue" when my baby boy is screaming in excruciating pain.
It was an accident. Everyone makes them. But please don't make light of a fractured bone just because the baby has respiratory and neurodevelopmental problems. That's hurtful and untrue.

5:26 PM  

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