Unplanned extubation while on orientation - page 2

I'm in my third week of orientation and just finished my third shift of caring for stable, intubated babies. While doing my assessment on one of my patients, after inline suctioning, his HR and sats... Read More

  1. by   NicuGal
    We quit doing daily X-rays years ago. There is not a need unless you are having an issue. These kids are getting a lot a radiation over time.
  2. by   ckey01
    We don't do daily x-rays on our intubated kids, but we do get them at least weekly. I was surprised when OP said it had been 2 full weeks.
  3. by   Jory
    They bring up a portable X-Ray unit and they do it right through the clear top of the isolate. But yes, daily.
  4. by   cayenne06
    I am not a NICU nurse, but daily CXR does seem like an incredible dose of radiation. Aren't these kids sometimes intubated for weeks or (?) even months?

    eta- But to echo previous posters- you did a GREAT job. You called for help when you realized you couldn't manage the problem yourself. I wasn't there with you, so maybe you did make a mistake. Maybe you didn't verify that the tube was correctly placed in relation to the mouth, or maybe if you've been caring for this baby for a while you should have thought to double check on the CXR order. But it doesn't really matter. You can be the most skilled, experienced nurse on the unit, and you will still have scary "oh sh*t" moments, and you will still have tragic outcomes. Usually it has nothing to do with your skill. But, sometimes, you will make a mistake and directly contribute to a less than ideal outcome. Such is the nature of being human. What makes you a good nurse is that you continually strive to provide the best care you can, you recognize your limits and never hesitate to ask for help, and you take responsibility for your patient's outcome- LEARN from it, get better at your job. Based on your post, it is clear to me that you are a competent and compassionate nurse. I would feel confident in having you provide nursing care to my own child, if (heaven forbid) it was needed.

    You deserve a glass of wine and a bubble bath. What a crazy career we have chosen.
    Last edit by cayenne06 on Jun 21, '15
  5. by   Jory
    Quote from cayenne06
    I am not a NICU nurse, but daily CXR does seem like an incredible dose of radiation. Aren't these kids sometimes intubated for weeks or (?) even months?.
    That would be correct.
  6. by   NICURN29
    I had a patient self-extubate when I was on orientation. My preceptor asked me if I was comfortable bagging her, and I said no, so she did it. Once it was obvious the tube was out, we called for the NP, who reintubated. The parents were standing at the bedside through the whole thing.

    A few years ago, the mom stopped in to visit because she was in the area. She immediately recognized me as the baby's nurse that night and said, "Thank God you were standing right there and got her help right away." Her memory of the incident is that I helped her baby. Until that moment, my memory was that I had made a mistake...but I was able to let that go finally.

    These things happen. No one expects you to know everything right away...that is why there is a long orientation process. It sounds like you did the right thing calling for help...even more experienced nurses have to do that sometimes!
  7. by   NICURN29
    Quote from Jory
    There's the problem. Most NICU's do a daily X-ray to check for ETT placement.
    I would not agree that "most" NICUs do daily CXRs for tube placement. In fact, that is contraindicated by the evidence. While your L3 may do that, mine does not. We do sometimes do daily CXRs on intubated babies if we are following the development of their lung disease, but they are not done just to check tube placement.
  8. by   Jory
    I'm not the medical director so it's not my decision. I can tell you that it has revealed many, many problems and unplanned extinctions are rare here.
  9. by   aerorunner80
    That nurse was right. We have all had it happen at one point or another. My advise to you is to ease up on yourself. Nobody expects you to know what to do or how to react in an emergency situation like that. But what you can do is learn by watching and next time it happens (because it WILL happen again), you can go in with a smudge more confidence and do one thing such as recognizing that there is a possibility your baby is extubated.

    Being a new nurse is like taking a series of baby steps. You learn and experience a little here and a little there. Then one day it all clicks. It takes several years to have those moments but trust that they will come.

    If you were my orientee in your situation, I would have been happy that you knew there was some sort of problem and MOST IMPORTANTLY you called for help when you needed it.

    It's the new people that don't call for help that are worrisome.
  10. by   Coffee Nurse
    One of our attendings emailed this around the other day, it reminded me of this conversation. From a national survey to identify overused/unnecessary tests in neonatal units:

    "Avoid Routine Daily Chest Radiographs Without an Indication for Intubated Infants -- Although intermittent chest radiographs may identify unexpected findings, there is no evidence documenting the effectiveness ofdaily chest radiographs to reduce adverse outcomes. Furthermore, thispractice is associated with increased radiation exposure."

    Ho T. et al (2015). "Choosing Wisely in Newborn Medicine:Five Opportunities to Increase Value." Pediatrics 36(2). (Sorry my APA is a bit rusty.)
  11. by   wensday
    This has happened to everyone at some point, so absolutely don't blame yourself!
    IMO someone should have gone though bagging with you, then you have the option of doing it straight off. Not your fault, just something maybe your preceptor will do next time they have a newbie.
    In years to come it will happen to someone new and they will feel the same as you do now. You can be there to bag the baby and say 'dont worry, happens to us all' x
  12. by   wensday
    Quote from NICURN29
    I would not agree that "most" NICUs do daily CXRs for tube placement. In fact, that is contraindicated by the evidence. While your L3 may do that, mine does not. We do sometimes do daily CXRs on intubated babies if we are following the development of their lung disease, but they are not done just to check tube placement.
    Same with us, we only CXR again if there is an unexpected deterioration and we are considering our options- infection, collapse etc.
  13. by   angrykitten
    Just to echo what everyone else has has said, you did exactly the right thing by realizing you needed help and asking for it. Unplanned extubations happen in the NICU to nurses who have been there twenty years and nurses who have been there twenty days. When ETTs are only in 6-10 cm you don't have a lot of wiggle room. Regardless of what the CXR policy is in your NICU, now you know what to do if something like this happens again. You will still have to ask for help. You can't bag the baby and reintubate them by yourself.

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