NICU training ?

[Hope4Ava]

I had twins born at 24 weeks. They were boy, girl weighing 485g and 502g respectively. My little boy did a lot better than his sister which brings me to the point of my post.

After visiting early one morning they'd discovered she had a grade 4 IVH and she just wasn't doing well at all so we decided to make her a DNR then later decided to just take her off life support. My husband and I both wanted to be there so I asked that they wait until we returned (he was at work) and it was agreed. At this point the babies were 47 days old. While I was gone to get my husband my daughter coded and died.

To make a long story short I'm leaving some stuff out, but when we got to her bedside and around the screens they put up we found two residents, two RT's, a nurse and an attending all standing around her bedside laughing and giggling while trying to intubate our deceased daughter.

I trusted the care of my babies at this hospital as I was a staff nurse in this very NICU up until the point my pregnancy got too complicated. I'd worked there 2 years total and had NEVER seen them do this.

So in a long drawn out way my question is........do you do this often as part of your training........if you have kids and even if you don't I'm sure you can imagine how it felt to walk in a see this being done on my child.

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[edmadison]

What happened to you is reprehensible and I'm sorry for your loss. In the "olden days" it was common practice to use deceased patients to practice procedures such as intubation. You may even recall an episode of ER where this was raised. In the six institutions I have worked at, I have never seen or heard of this happening. I thought it was a thing of the past. I hope that you at a minimum made a formal complaint to the hospital. The staff involved needs to be disciplined for both their acts and their attitudes.

Ed

 

[michigangirl]

I can definitely say I have NEVER seen this happen in my many months of rotating in the NICU as a resident...I am so sorry this happened....residents, RTs, attendings, are almost always very sensitive to issues of death and dying in the NICU, the very nature of the patients deems this necessary. Although we can never feel a parents loss completely, I and my colleagues are always deeply saddened when a death occurs...just yesterday I had to console an intern who was crying so hard she couldn't perform her work. Please understand that this was a rare occurence that happened, and I am sorry it happened to you and your husband.

 

[Hope4Ava]

Thank you for your responses. I'm a NNP now and still haven't seen this done in any other facility I've worked or trained in. It was 3 years ago and obviously it still bothers me. But knowing it's not that common gives me a little peace and now I guess I can truly move on. I know my daughter Ava is safe where she is and now it's time for me to not worry about her.

 

[FunnyLookingKid]

I had twins born at 24 weeks. They were boy, girl weighing 485g and 502g respectively. My little boy did a lot better than his sister which brings me to the point of my post.

After visiting early one morning they'd discovered she had a grade 4 IVH and she just wasn't doing well at all so we decided to make her a DNR then later decided to just take her off life support. My husband and I both wanted to be there so I asked that they wait until we returned (he was at work) and it was agreed. At this point the babies were 47 days old. While I was gone to get my husband my daughter coded and died.

To make a long story short I'm leaving some stuff out, but when we got to her bedside and around the screens they put up we found two residents, two RT's, a nurse and an attending all standing around her bedside laughing and giggling while trying to intubate our deceased daughter.

I trusted the care of my babies at this hospital as I was a staff nurse in this very NICU up until the point my pregnancy got too complicated. I'd worked there 2 years total and had NEVER seen them do this.

So in a long drawn out way my question is........do you do this often as part of your training........if you have kids and even if you don't I'm sure you can imagine how it felt to walk in a see this being done on my child.

first of all, I'm sorry for everything that happened to you. I won't go into any mediacl details, but for this to happen at 47 days seems to me quite odd ( given the limited intformation you shared )

this should NEVER happen and this behavior is totally wrong. I think you should complain to the chief of the department ( in writing )

People respond to stress in different ways. "gallows humor" is fairly common in ICU's, operating rooms, etc. Health care workers do make jokes about what seems to an outsider to be a very tragic circumstance.
I do not condone it, but I want to explain that this is very common.

Teaching intubations on deceased patients still happens. I can recall, the OB residents all rushing over to intubate stillborns.

We would do this, ONLY after having a conversation with the family and getting consent FIRST. Also it would be done with the utmost respect.

I assume you were at a teaching hospital.
I don't blame the residents. Residents generally follow examples. Sounds like they are following a bad example from their attending.

This is just tragic, and again I apologize. Not every NICU is like that ( thank God )

 

[Old MD]

She is NOT an outsider. She is a nurse who used to work in that very nicu. I'm not surprised that even an "insider" would have felt that way - I'm in no way related to Hope4ava's kids, and I'm absolutely mortified at what she describes.

The issue of ethical resident training is difficult, complex and not at all straight forward. Firstly, it is obvious that it is entirely necesary. Every generation needs doctors, and for our kids to have them we need to train med students and residents. Secondly, there is no way to train someone in medicine without having them actually practice medicine. Herein lies the dilemna - to train doctors, we must allow them, as students, to practice medicine, yet by definition when they are students, they are non-expert. And so training is "stolen", as atul gawande opines in his bestselling "complications".

If we completely bar residents from intubating live patients, how are we going to get them to be sufficiently skilled? Intubation is a very dificult, and very important, skill. Mannequins just don't cut it. One day, another baby's life will depend upon the skill those residents were gaining partly through practicing on this little girl.

I think the thing that repulses us here is not so much the tubing, but the mirth. The laughter. The disrespect, some would call it. It is a callousness - while they were essentialy using this little girls body to help gain a skill, they were being completely cavalier about it. Her death was taken for granted.

It should not be so. I personally feel the only way to reconcile the issue is informed consent. Intubation should be performed by trainees only when the patient is going under anesthesia in controlled conditions, in the morgue, in the ED (with appropriate backup).

 

[ERMudPhud]

Herein lies the dilemna - to train doctors, we must allow them, as students, to practice medicine, yet by definition when they are students, they are non-expert. And so training is "stolen", as atul gawande opines in his bestselling "complications".

If we completely bar residents from intubating live patients, how are we going to get them to be sufficiently skilled? Intubation is a very dificult, and very important, skill. Mannequins just don't cut it. One day, another baby's life will depend upon the skill those residents were gaining partly through practicing on this little girl.

I remember when I was teaching residents how difficult it was and how much it made my hands itch and my stomach churn. I just wanted to push them aside and do the procedure because I knew I could do it faster and with less risk and discomfort to the patient than they could. I always had to remember my own residency experience. As a chief resident I spent a month intubating babies with a peds anesthesiologist. I am sure her fingers itched and stomach churned watching me intubate her patients. Shortly after that I was in the ED when a <30 weeker born to a crack addict with no prenatal care was brought in by EMS apnic and bradycardia. We usually had a rather aggressive attitude in the ED and felt that all procedures belonged to us. In this case the Peds chief happened to be in the ED and so I overruled and told him to take a shot at the tube. After he and others failed on the tube I figured I had to give it a shot. With my memory fresh from my Peds anesthesia elective I took a look. Everything was way smaller than even the smallest baby I had previously intubated but just as I was about to give up the baby gave this little squeak and a bubble came out his larynx. As I put the tube in I came as close as I ever have to believing in God. The kid was D/C'd from the NICU in pretty good shape some monthes later. My own practice and training the month before is what made it possible.

As for post mortem procedures. I did them as a resident but never felt comfortable with them. We were doing them without consent on trauma DOA's. I do know of at least one life saved as a result. I cric'd a patient with horrible angioedema of the face and throat and I definately couldn't have done it without some of the DOA experience. Even still I feel uncomfortable with the idea of doing and teaching post mortem procedures.

The inappropriate behaivior is the real problem here as well as the lack of consent. We've all slipped into gallows humor and hopefully we all realized we were wrong when we did.

 

[RuralMedicine]

First I'd like to extend compassion and empathy to Hope and I appreciate your willingness to share your experiences with this forum. I've learned a lot from my patients and their families and suspect I will continue to do so. I agree that it is sometimes a challenge to remember that our patient are human first and humans with illnesses and disabilities second. I offer this not as an excuse for your experiences (as there isn't one) but as a renewed challenge to myself to continue.

I remember when I was teaching residents how difficult it was and how much it made my hands itch and my stomach churn. I just wanted to push them aside and do the procedure because I knew I could do it faster and with less risk and discomfort to the patient than they could. I always had to remember my own residency experience. As a chief resident I spent a month intubating babies with a peds anesthesiologist. I am sure her fingers itched and stomach churned watching me intubate her patients. Shortly after that I was in the ED when a <30 weeker born to a crack addict with no prenatal care was brought in by EMS apnic and bradycardia. We usually had a rather aggressive attitude in the ED and felt that all procedures belonged to us. In this case the Peds chief happened to be in the ED and so I overruled and told him to take a shot at the tube. After he and others failed on the tube I figured I had to give it a shot. With my memory fresh from my Peds anesthesia elective I took a look. Everything was way smaller than even the smallest baby I had previously intubated but just as I was about to give up the baby gave this little squeak and a bubble came out his larynx. As I put the tube in I came as close as I ever have to believing in God. The kid was D/C'd from the NICU in pretty good shape some monthes later. My own practice and training the month before is what made it possible.

In my experience (and with the disclaimer that I'm still a resident) when intubating apneic neonates* in the delivery room we sometimes underestimate the advantage of establishing the airway and providing positive pressure ventilation in our eagerness to intubate. Establishing an airway and ventilating are the most critical aspects of neonatal resuscitation for the majority of infants. This can be done without an ET tube (although in this group more than older children the argument of more effective ventilation through an ET tube is more relevant). NRP recommends 30 seconds of PPV before any intubation attempts and intubation attempts should always be limited by bradycardia. Additionally I've found that intubation is easier after the infant has taken that initial (agonal or not) gasp as you may be visualizing closed cords which you can not pass a tube through prior to this. I hope (and presume based on your outcome) in your example of multiple intubations for the infant that throughout the process they were not bradycardic. Your story I think does illustrate the closed cord phenomeon quite well. Also do not forget to dry, and warm the infant and remove wet linens. Hypothermia can easily lead to arrest in this age group.


*Depressed meconium infants will be the exception where you really need to tube first and then go but either the kid better be screaming when you pull that ET tube out, less than 30 seconds have passed in your resuscitation or you have an adequate heart rate (so you intubate with a second tube) or its time for positive pressure ventilation. *