Babies need 3.5s

Tonight the attending sent me in to see a premature 3 month old baby (actual age was then probably only a few weeks old) with trouble breathing. I had no chart, no parents, no history, just a baby on a bed gasping for air. I thought about the recent “cyanosis in the newborn” lecture I’d had, but she wasn’t cyanotic. She was really struggling hard and had several second pauses of no breathing at all. I got the infant bag valve mask out to help her breath…of course, there’s that moment when you need a piece of equipment NOW, and you can’t find it…that part was scary. SO I began assisting ventilations. I’m still by myself in the room. One of our interns (who served 4 years as a GMO in the Navy, so he’s got more experience than I do) asked if I needed help. I asked him what size intubation tube to use for a newborn. I wasn’t pimping him (pimping is how we torture interns to make them feel like they never learned anything in medical school). I just had brain freeze. I had no idea what tube size to start with, but I knew that this baby wasn’t breathing well on her own. So now there are just the two of us in the room with this struggling baby who I still don’t know anything at all about.

The intern got the “broslow tape” out, a color coded ruler that you lay next to a child to quickly get all the emergency equipment sizes and drug doses you need. He pulled out the right sized tube and laryngiscope blade, and we had all the airway equipment set up on the bed.

FInally, the pediatric critical care attending shows up…man was I relieved! By now, we’re full on bagging the kid (breathing for her), watching her oxygen saturation go up and down depending on how good our technique is (I’ve never bagged a baby before). He sees the airway equipment and considers our plan and agrees that she needs to be intubated.

One by one more help arrives. First a nurse…who dissapears to get a tech to help do a heel stick for blood, the portable x-ray machine is waiting for us, but we decide to just go through with the procedure.

TO make a long story short, I took two attempts, saw the opening of her trachea and couldn’t pass the tube. This was without paralysis. I was so nervous about the whole thing that I couldn’t even remember how to hold the blade or ge the mouth open. Everything was so tiny, I could hardly see. One eyeball could see down her throat, and I had to tune out messages from the other eye because all it was seeing were bedsheets. Meanwhile, there are now about a dozen health professionals standing around watching a struggling baby…no one likes to see that. It’s one thing to see a 90 year old take their last breaths, but a baby is way different. Some how I’m able to tune out all those people standing around. By this time respiratory has arrived, anesthesia has arrived, the pediatric team has arrived and various other nurses I’ve never seen before.

THe critical care doc steps in, decides to paralyze and then gets the tube into the right spot on the first try, we attach the ventilator and proceed with her stabilization.

So that was my stress for the day, and now I’m anxious to try another one because I know what I did wrong. I know why I couldn’t get the tube in. I was using my laryngiscope blade wrong! I am used to a certain type, but there are lots of different blade styles. My brain was just frozen and couldn’t adapt to the change, even though I’ve used that blade dozens of times before.

I was not confident. But I did not have a choice about whether or not to act. THat being said, there were lots of things I did right, based on the experience I did have with adults in respiratory arrest. THey say that kids are not just “little adults”, but many of the same things needed to be done. I recognized the problem, prepared the equipment, organinzed our nurses based on the critical care docs suggestions, gave medication orders, and most importantly, I DID NOT stick the breathing tube into her stomach, which can be fatal if unrecognized. THose were all good things.

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