DR fail

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Specializes in NICU.

So I am 4 months into working in the NICU as an RN with 6 years adult experience and no ped/baby experience. I have been off 'official' orientation about a month now in my level 3 NICU, yesterday we had multiple deliveries and I was asked if I felt comfortable going to a delivery and admitting a 28 week twin. This was my youngest admit so far, and might I add FIRST delivery, I love what I do and am eager to learn and get as much experience and practice as I can, so I said I felt I could do it as long as I had help, which I knew I had as everyone has been wonderful in teaching and offering assistance. I told the NNP when mom was at 4.5cm that I would be delivering with her and that when the time came, I needed her to tell me what she needed of me and to help guide me through the process. She was appreciative and agreed.

My kid ended up breech while mom was in active labor so they called a stat section. Charge nurse told me to hang back a bit while the other twins admitting nurse checked the section room. There was miscommunication between charge and the other RN, she did not check my bed, only hers we found out.

The section room was a cluster to put it nicely, during the time the incision was being made the NNP I was working with was looking over the bed and noticed multiple things missing and I did not know where to find them, I think she was also upset things were not set up appropriately, and the other girls from the L&D and the floor did not know where to find them either (I think they must be newer too), so my NNP had someone run back to the unit to get me help. Baby came out after my help arrived, baby was dried, stimulated and put in bag, no breath or tone, PPV was immediately started, I counted 40HR, baby was intubated and I started chest compressions, we still did not hear respirations and the suction was not working (not checked prior because of the miscommunication between my unit and also missed by L&D who sets up and checks before us)so NNP retinubated, I counted 50HR and continued compressions. The fourth or so time counting respiration I think the adrenaline and everything together got to me and I kind of mentally froze and could not concentrate or hear enough to count confidently so I requested my help to count. HR was then 100 just over a minute later and we had a sat of 70%. We brought baby back to the unit and started lines and the admitting process.

The other twin did not have as rough a time as my kid, I'm beating myself up because I don't feel I prepared myself appropriately and think I jumped the gun on this one. My baby was down to 25% FiO2 when I left him and I had him already titrating down on his dobutamine drip that we started 6 hrs after birth because his art line BP MAP was fluctuating between 23-27.

We had a de-briefing between myself, the NNP and my RN help. We discussed what went wrong, how I did, how we communicated and what we could have done and what we learned to improve future deliveries. They all said I did great for where I'm at, I kept calm, despite freezing up in the DR and being very unorganized, I feel I did my very best and they felt that I did too but then I got so emotional I started to cry and I am just so embarrassed.

I'm upset I did not respond to these events quicker and in a more organized/appropriate fashion. Many of the girls came up to me throughout the night to offer support and one girl even texted me this morning, I feel I have the support and resources I need to be successful but can't get over how poorly I feel I performed!

Does anyone have any similar experiences and what did you learn from it? Do you have any suggestions on how I can improve myself?

Thanks in advance for your responses.

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Specializes in Emergency Medicine.

I'm not a NICU nurse but can offer my insight-

Remember your first several adult codes? How did those go? I bet you felt then, how you feel now. I like to always be prepared, maybe if able, you can check the room prior to delivery to make sure everything you need is there? I personally trust no one- for example, even if trauma bay checks have been done, if I'm the trauma nurse, I go over the room and each bay to make sure I have what I need.

Don't beat yourself up- the baby lived and got the care it needed. Next time you will know to focus more and what you can expect. You're still new, listen to the suggestions from the debriefing and be open. It's always good to let others know what you don't know- that is the sign of a great nurse.

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Specializes in Pediatrics, NICU.

Aww, you had a very rough night! The overall impression I'm getting from your story is that you were kind of set up for feeling like you failed here. Some things I picked out from what you wrote:

1) You should have had more guidance with delivering and admitting a 28-weeker after only being off orientation for a month. I know you said that help arrived before the baby came out, but I think you would have felt less panicky if someone had been with you the whole time instead of just coming over when things were already not going well.

2) It sounds like there was lots of scrambling around and breakdowns in communication in L&D and among your NICU nurses. That certainly contributed to things not going smoothly for you and the NNP.

3) Your baby just got off a bad start! This has nothing to do with you however. It sounds like the baby's APGARs were probably between 3-5 and he then went on to require intubation, chest compressions, and later dobutamine.

4) You followed NRP guidelines and jumped right in on chest compressions after drying, bagging, and then intubating. So well done there!

5) Your coworkers sound very supportive and eager to help you succeed! That's not the culture on all units so count yourself fortunate.

As for improving yourself, now you know to check the equipment and to try to foresee things that you'll need to do in worst case scenarios. Also, try not to get panicky when things aren't going smoothly, even when others around you are scrambling. You'll think more clearly if you take a deep breath and just fall back on your training.

I think you performed better than you thought you did. Maybe not as well as you wanted to, but you will find similar situations easier in the future now that you have this experience behind you. :)

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Specializes in NICU, PICU, educator.

This one of the Live and Learn times! And as a new person you did the best you were able! The ball was dropped by whoever in L/D didn't set up the tables, we don't get there and need to be setting up, we just need to get there and check out equipment.

You did it, you survived! And now you have that new experience under your belt! Hang in there!!!! Every one of us had had an experience or two or three like this, and teamwork is vital, good coworkers are vital and when all is said and done you go to the bathroom or supply room and get it together! Once that adrenaline rush is over it hits and just let it ride!

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Overall, it sounds like you did really well considering you are a month off orientation! I think it was irresponsible of your unit to expect you to handle a 28-weeker delivery, especially when you were just off of orientation. Even the seasoned nurses in our unit take a second person with them to a micro-preemie delivery in case there's a code or just for back-up - and we get a lot of micro-preemies.

Whenever you are thrown into a situation like this where things are not set-up, make sure to quickly check all the most important things first like suction (tubing, mec aspirator, Delee, make sure settings are appropriate) and respiratory equipment (intubation supplies in the right sizes, etc). And always check everything yourself if you can. I can't tell you how many times I've gone to check equipment and there are several things missing. It happens. I even take a small bag filled with supplies I might need every time I go to a delivery in case the supplies are not already on the table. You never know what you're going to walk into when there are multiple deliveries a day.

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Specializes in NICU.

Wow, the nursing community never seems to fail me, I am always surprised by the wonderful support we offer each other every day. Thank you all for your wise comments and suggestions, I needed that little boost of morale as well. My unit has been wonderful about this, the event was brought to the hospital safety huddle and I think we are all learning from it. I am appreciative for the event because looking back on it I see now how much I learned from my mistakes! And I am amazed by how apologetic my unit as been for 'putting me through that' as they say. I have great a great support system there I just need to take more advantage of it and learn my boundaries, I can't expect so much of myself right now.

I watched a 35 wk scheduled section yesterday and it was wonderful to be able to step back and incorporate everything without really being involved. So that was very helpful.

Thank you everyone:)

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My disclaimer is that I'm an OR nurse, not a NICU nurse. But things are chaotic under the best circumstances whether in the OR itself, L&D or L&D OR, particularly in emergencies. Sometimes we're asked to help cover the L&D ORs and sometimes we do crash sections in the Main OR. We did one a while back where the rationale for the delivery in the Main OR was the expectation that we'd have to crash onto ECMO for the mom - and we did. It was messy but baby made it to NICU just fine, and mom made it to STICU to hang out on ECMO until strong enough for the heart surgery she needed.

I'd agree with what others said - this was your FIRST experience with this type of emergency situation. Rarely (my experience: never) are you ever comfortable the first time you do something, especially in an emergency!

No emergency situation feels "comfortable" as a new person. I just recently, had an emergency situation where I felt comfortable in that particular type of situation, 3.5 years into my time as an OR nurse. If it were another situation and something I was less familiar with I would have felt like I handled it less well. I also know I'm my own biggest critic, significantly harder on myself than anyone else.

You've considered what you might do differently which is the important part to facilitate your learning! Next time will be better! :)

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Specializes in Telemetry.

I've only worked tele, but it sounds like you performed to the best of your abilities in the situation.

I agree you probably felt nervous and clumsy during your first codes in adult acute care, and it would seem expected to feel a little like a newbie in this new and different setting.

Sounds like your unit is supportive and not punitive, which is fantastic. Hopefully everyone can learn from this situation and with time you'll feel a lot more in control.

Best of luck to you - and although I'd be nervous as heck with those teeny tiny babies, I hope your back has a longer life span than it did on the adult unit. :)

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Specializes in NICU.

This very similar thing happened to me when I was new off of orientation. We had a slam busy shift with admits (two criticals needings vents and lines) and there was a 36 week twin delivery we were called to (we go to all twin deliveries at our facility just in case there are any issues since it's technically considered high risk.) My charge asked me to go along with a senior nurse as there were no other options for staff to go and at the time I was not experienced with lines or vented kids. We did not set up the beds as the OB nurses assured us they had done it and when we got there the beds were already sterile draped. Well of course the first kid came out fine so I went to that one and the senior nurse took the second one in case that one needed help. Well my first twin became apneic about 1 minute of age and of course the neopuff wasn't even set up! The alternative bag/mask was inside of the bag still and was not set up at all, the O2 was not plugged into the wall like it should of been and the OB nurse completely froze and was no help. I had to yell to the senior nurse and stretch her neopuff tubing over to my kid who at this point was blue and limp and the senior nurse was yelling at me for not saying anything earlier when the child first became apneic. Thankfully the baby was Ok but it made me look really bad and I tend to be soft hearted so getting chewed out in front of other nurses was really embarrassing. I almost wanted to quit that day. I felt like I had been punished for trying to be helpful and flexible when they needed help the most. The other nurse saw how upset I was and pulled me aside to apologize for being so rude to me. Together we filled out a safety report and had a meeting with the OB manager. Since then our protocol has been changed and now even if the bed is sterile draped before nicu gets there we have to ask them to redrape after we check our own equipment since we are the ones attending and responsible for those babies. A lot was learned from that experience but it was traumatizing to say the least.

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