Unplanned extubation while on orientation

[tictac]

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 dropped to the 30's. My preceptor had just gone to lunch and left me under the supervision of a podmate. I yelled for her help and she came in and immediately started bagging. Long story short, the baby got reintubated after several attempts and appeared to be stable immediately post procedure.

I was told repeatedly that it happens to everyone and to not feel bad, but I can't help but feel like crap and totally incompetent. It was my preceptor's first time EVER leaving an orientee by herself and she felt somewhat confident enough in me to do so momentarily. I really don't know what I could have done differently, as I wasn't trying to reposition him or anything. Externally, everything looked like it was in place and the tube didn't visibly come out. They did say the ETT must have been sitting very high because there was a 1.5 cm difference in depth with the new one. This baby was just over 1 kg and I believe it had been 2 weeks since the last chest X-ray. I keep trying to tell myself that this was the primary reason this happened, but whether that's entirely true or not, I'm not sure. I'm not very confident in positioning all the tubing.

What bothers me even more is that I had no idea what to do after calling the other nurse. I just stood there as everyone else took care of him. I didn't even know to start bagging him right away and observe for chest movement or listen for breath sounds. Although I don't complete NRP until next week, I feel like this is something I should have known, being a nurse. I'm completely paranoid that I'm going to do this again and my confidence has dropped to zero.

You guys are a tremendous resource and if anyone has any words of wisdom regarding these situations, I'd be eternally grateful. Thanks for letting me vent (no pun intended).

[Coffee Nurse, BSN, RN]

...and I agree that it does add up over time. However, that is what they do here. The rationale I was given is that many times that you can identify an ETT out of place before it gets to the point that the baby is having problems. It is a Level III.

But daily? Babies grow fast, but not that fast, if all you're checking for is them growing out of their tube placement. I'd imagine you're more likely to have dislodged the tube from all that unnecessary moving by the time you catch one outgrown tube.

[NicuGal, MSN, RN]

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.

[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.

[Jory, MSN, APRN, CNM]

They bring up a portable X-Ray unit and they do it right through the clear top of the isolate. But yes, daily.

[cayenne06, MSN, CNM]

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.

[Jory, MSN, APRN, CNM]

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.

[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!

[NICURN29]

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.

[Jory, MSN, APRN, CNM]

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.

[aerorunner80, ADN, BSN, MSN, APRN]

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.

[Coffee Nurse, BSN, RN]

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.)

[wensday, MSN, RN, APN, NP]

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