Friday, November 03, 2006

Scrutiny

The baby had been sick before she was born. At 29 weeks gestation mom came to the OB clinic with the baby poorly grown inside her. The baby wasn't moving much, and the baby's heart rate never varied, an often ominous sign. The heart was big and there was fluid in the abdomen. After they delivered the baby that night she continued to be sick and gave us a real workout. She was on a conventional ventilator, then the oscillator ventilator, then a conventional one again, and finally after four days was stable and needing only a moderate amount of help from the ventilator. She still had a ways to go, but was looking like a more typical premature baby who just needs to grow and mature for awhile.

It was a surprise, then, when I came in the next morning and heard my partner tell me the baby had died the night before. Nobody was sure why. The nurses had been changing the IV fluids and tubing attached to her umbilical lines when the baby coded and could not be revived.

Deaths in the NICU can be roughly sorted into a few categories. The most common kind of death is the extremely premature baby, the immature 23 weeker whose lungs and other organs are just not mature enough to make it. Simply born too early, these kids usually die within a couple hours to a couple of days after birth. Another category would be those babies with terrible chronic lung disease who survive several months but are never good enough to go home and who finally die. These don't occur often nowadays but are always hard when they do because everyone has grown attached to the baby. Some kids will die from infection, although with Group B strep treatment of the mom in labor and liberal use of antibiotics in newborns these deaths are becoming less frequent as well.

The deaths, though, that drive me crazy are the ones like in this baby, a child who is doing well when something unexpected and unexplained happens. This seems like the type of death that is the most preventable and deserves close scrutiny. As soon as I have time and the chart is available, I'll go over it closely to see if I can find any clues to the reasons for this death. I'll talk to my partner who was on duty at the time, and maybe to the nurse. I'm not trying to blame anyone; I just want to see if there is something we can learn from this, something we can prevent from recurring.

When bad things happen in the NICU, you can take one of two attitudes. You can say "Oh well, some tiny babies are bound to die," or you can try to examine the case and look for information that might give you even a tiny advantage in dealing with the next baby. I like to choose the latter approach. Paying attention to small details can help small babies survive, and that, after all, is what we do for a living.

9 Comments:

Anonymous Anonymous said...

Poor little thing. Perhaps, though, she is much better off in the long run.

1:21 PM  
Blogger What The Hell Is This? said...

And in the latter months, as the parents deal, this attitude is one that will be appreciated. Maybe in time, the death of their child will be one that they can look back on and say "because of her, another baby could possibly live"..
Being in the 23 weeker, just too immature to survive, category, I wish that was the least I could say.

GL and keep doing what you are doing.

1:47 PM  
Blogger Flea said...

Don't forget congenital anomalies incompatible with life such as Potter syndrome.

Have a great weekend.

Flea

2:02 PM  
Anonymous Dianne said...

Is there going to be an autopsy on this baby? From what you've said, I would guess that there was some cardiac anomoly that led to arrest. IIRC, cardiac arrest is fairly rare in children--they usually suffer from respiratory arrest initially followed by cardiac failure--but that could hardly be the case for a child on a ventilator (unless the ventilator failed in some way.) Did the child ever have an echo? Could she have received some med that led to torsades?

I'm sorry about your patient. I imagine that you were probably getting attached to her. My instinct when a patient dies is think back over their care, wonder why it happened, what could be done differently, too. Maybe it's easier than feeling the loss, but at least, maybe, you can find a way to help the next patient.

2:23 PM  
Blogger Fat Doctor said...

I hate to ask, but was this partner on duty the same one you've had issues with in the past? Just curious.

7:52 AM  
Blogger neonataldoc said...

Fat doctor, the doctor and nurse in this case were each one of our best. It was not the one I wrote about earlier. Dianne, no autopsy permission was given. Flea, you are correct, but those deaths become less frequent as they are diagnosecd prenatally now and terminated.

9:04 PM  
Anonymous Anonymous said...

Neonatal Doc,

A bit OT, but when you talk about the kind of things you have to help the newly-born with, I have a question for you...do you ever have see cases of babies having issues caused by drugs (pain meds in particular) used during labor? What kind of problems have you dealt with in this area (if any)?

There are many different sources of information out there....some saying meds can't hurt the baby at all and there is no difference between babies born with meds in their system and those born without to the other end of the spectrum where some believe that the risks are real and meds are best avoided unless completely necessary.

What is your experience as a neonatal doc?
Thanks!

12:20 PM  
Blogger neonataldoc said...

Anonymous 12:20, I think we can take a middle of the road approach to using pain meds in labor. Pain meds used reasonably can be a great aid to women experiencing pain in childbirth, and I'm all for decreasing pain. These kids are pretty resilient. But indiscriminate use or inappropriate use can be trouble.

2:08 PM  
Anonymous Anonymous said...

Thanks for your comments, Neonatal Doc. I agree with you.

But, I find it frustrating when other doctors (in this case an OB) says things like "it is not any healthier for you or the baby to avoid pain meds during labor".

There have to be some risks. This statement makes it sound like there are NO risks. The risks may be small but if the choice is between no meds with absolutely no risk vs. meds with some (no matter how small) risks...then, I would prefer to have the 'no risk' option and keep drugs as a last resort option.

It is not like comparing vanilla ice cream with chocolate ice cream (med. vs. natural birth). One does carry risks that the other does not.

I was looking for an honest answer from someone who actually works with newborns and knows whether or not the drugs have any risk to a baby. So, thank you for your response.

4:23 PM  

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